This form is for agencies and organisations referring on behalf of their client only. For self-referrals please contact our head office via email: [email protected]
All sections of this form must be completed.
Failure to do so may cause delays.
If for any reason a section cannot be filled out, please state why.
Blank sections will not be accepted.
Please be aware that your data may be shared with local authority Housing Benefit departments; the referral agency that directed you to CHM Care Ltd (e.g. Social Services or Health), Home Providers under the Cliveden Housing Management & Care Ltd umbrella and also with other bodies (such as Police or the Courts or Probation – if appropriate) where they have a legal right to access. In all such cases, Cliveden Housing Management & Care will ensure that a ‘data exchange agreement’ is in place, which will ensure that data is only used for legitimate purposes. This is however subject to one important exception. In some limited circumstances, we may be legally required to share certain personal data, if we are involved in legal proceedings or complying with legal obligations, a court order, or the instructions of government authority. In these instances, we will always endeavour to inform the individual concerned. Our full Privacy/Procedure can be viewed.

Please download the word document below and complete the form.

Simply email the completed form to: [email protected]